Assessing prevalence, factors and health consequences and academic performance of undergraduate students with breakfast skipping during COVID-19 using statistical modeling: a cross-sectional study

The study was conducted in order to study breakfast skipping (BKS) frequency, factors associated with, health consequence and undergraduate students academic performance during Covid-19 pandemic as earliest studies focusing on this area. A cross-sectional study was carried out among 2225 of undergraduate students. The study was carried between the period of 15/1/2020 to 3/4/2020 using an online self-report Breakfast Eating Habit Survey (BEHS). The BEHS survey was divided into two sections. The first sections included sociodemographic information (gender, BMI, age, smoking, residency, parental education, family income, studying system and stage (public or private), and studying institution (university or institute) academic performance. The second part included questions regarding breakfast eating habits including frequency of skipping meals, factors related to BKS health consequences and types of snacks. Logistic regression is a common technique used for modeling outcomes that fall into the range of 1 and 0. For this purpose, a logistic regression was performed to find adjusted odds ratio and crude odds ratio. The results showed that the majority of participants were female (1238, 55.7%). Out of 2,224 students, 2059 are aged between 18 to 24 years. Most of the participants were from first level (26.5%), second level (32.8%), third level (17.6%) or the fourth level (21.3%). Over 92% of participants were single and about 68% came from families of medium income families. The statistical analysis showed that the odds of BKS is reduced among students who live in accommodation by 54% (odds ratio = 54%, CI (41–71%), p value = 0.000). It seems that students with low income and normal or higher BMI are more likely to skip breakfast more regularly. The odds of skipping breakfast among students with BMI of 18–24.9 is reduced by 41% (odds ratio = 59%, CI (27%-93%), p value = 0.027) and the odds of BKS is reduced among students with BMI of 25–29.9 by 45% (odds ratio = 55%, CI (31–95%). Additionally, students with medium or high incomes are more likely to skip breakfast as much as twofold in comparison with students with low income (medium income (odds ratio = 1.85, CI (1.08–3.17), p-value = 0.024), high income (odds ratio = 1.98, CI (1.12–3.51), p-value = 0.019). The most common reasons for skipping breakfast included include time constraint, not hungry, breakfast is not ready, afraid to be overweight and lack of appetite. The consequences of skipping breakfast were feeling hungry throughout the day, feeling tired, and not paying attention in class and low academic performance. To concluded, BKS during Covid-19 is more common among students with higher BMI, higher income and living in accommodation. The main reason is time constraint and the most common health problems are being tired and luck of attention.


Introduction
Breakfast is one of the most important meals throughout the day.It can provide and fuel the body with required energy and micronutrients following a long night fasting [23].
Breakfast could also play a crucial role in improving body well-being and preventing some non-communicable chronic diseases [23].In contrast, breakfast skipping (BKS) could cause many cognitive and health problems including lack of focus and low academic performance [19].Furthermore, BKS might be difficult to compromise and could lead not just to ingest more calories and overeating [21], but also Extended author information available on the last page of the article consuming less important micronutrients like vitamins, fibers, minerals and phytochemicals [25].
The year of 2019 was recognized by the emergence of Covid-19 and caused the impose of several changes in life style routines as a results of mandate lockdown and confinement [5,20].For instances, educational institutes were closed, classes become at-distance and/or online.These changes affected students eating behavior including more vegetable and fruits as well as snacks and meals.[6].Studies have shown that snacks were consumed more by 52% [22] and breakfast by 5% [20] Dietary habit and lifestyle are profoundly influenced by the spread of the Covid-19 particularly among youngsters.According to literature available, BKS is more prevalent during Covid-19 among youngsters than older adults [7], particularly among undergraduates which related several well-being compromising behavior [3,18].Consequently, it is more likely to lead to several negative health complications in short term.
Several aforementioned studies have connected BKS with increasing weight change, negative health consequences and academic performance.However, there is a shortage and more information is required to obtain an insight of the prevalence of BKS among large population of undergraduate students particularly in relation to health consequences, factors for skipping and academic performance during pandemics.Therefore, the aim of present study is to study BKS frequency, factors associated with, health consequence and undergraduate students academic performance during Covid-19 pandemic as earliest studies focusing on this area.

Participants and sample size
A descriptive cross-sectional study was carried out and sent to the undergraduate students in Kurdistan universities in a randomized sampling method.A pilot study was conducted to assess the validity and reliability of the questionnaire.Then, the questionnaire was reconstructed and rearranged accordingly.
The study was carried out among Kurdish students and a total of 2225 of undergraduate Kurdish students aged between 18-25 years old responded correctly.The study was carried between the period of 15/1/ 2020 to 3/4/2020 after emerging Covid-19.Due to the Covid-19 pandemic limited movement and to maximize student's involvement, the snowball online form was distributed among the students.

Breakfast Eating Habit Survey (BEHS)
A self-declared BEHS was designed based on the previous researchers with some modifications [24].It was then translated it to Kurdish language to ease understanding.The evaluation BKS and/or regularity and factors related to over a period of seven days.The questionnaire was divided into two sections.The first sections included sociodemographic information (gender, age, smoking, residency, parental education, average monthly family income, studying system (public or private), studying institution (university or institute).The second part included questions regarding breakfast eating habits including number of skipping meals, snack foods, factors and health consequences related to BKS.

Ethical approval and consent form
Ethical approval for University of Salahaddin-Erbil and consent from the students was attained before commencing this study.Students were ascertained that their personal information was voluntary and the information kept anonymous.

Statistical analysis
In the current study, a Chi-square test of independence was performed to investigate the relationship between BKS and student performance at the significant level of 5%.
One of the statistical techniques that is most frequently applied is regression analysis.Modeling the relationship between the explanatory and outcome variables is a crucial step in statistical modeling [10].The most prevalent illustration of this is linear regression modeling, where the outcome covariate is a number.Instead, logistic regression analysis can be used if the outcome covariate is a binary response.Logistic regression is a common technique for modeling outcomes that fall into the range of 1 and 0. For this purpose, a logistic regression was performed to find adjusted odds ratio and crude odds ratio.

Results
Sociodemographic information of the students is presented in Table 1.It can be seen that more than half (55.6%) of participants are female and the rest (44.4%) are males.The vast majority of the student age is between 18-24 as the typical university age followed by 6.25% aged between 25-30 and only 1.25 of the participants were more than 30.Furthermore, the vast majority (92%) of the students were single.University students (four years of study) participated by 91.6% and institute students (two years of study) were 18.4%.Similarly, the majorities (89.3%) of the students were from public universities and 14.7 were from private.Almost half of the students (48%) were from urban areas and 32.3 were staying at student accommodation and rural areas were 19.7%.The results also showed that the students come from low and medium and high income families were 4%, 67.8% and 28.2, respectively.Students' smoking cigarettes were 7.2%, taking shisha 8.2% taking both cigarette and shisha were 2.1 and the remaining percentage (82.6%)they did not smoke.
Table 1 illustrates a demographic overview of the participants.The majority of participants were female (1238, 55.7%).Out of 2,224 students, 2059 are aged between 18 to 24 years.Most of the participants were from first level (26.5%), second level (32.8%), third level (17.6%) or the fourth level (21.3%).Over 92% of participants were single and about 68% came from families of medium income families.
We have performed logistic regression models to find adjusted odds ratio and crude odds ratio.We have found that variables such as residence, BMI and income are statistically significant factors.The odds of BKS is reduced among students who live in accommodation by 54% (odds ratio = 54%, CI (41-71%), p value = 0.000).It seems that students with low income and normal or higher BMI are more likely to skip breakfast more regularly.The odds of BKS among students with BMI of 18-24.9 is reduced by 41% (odds ratio = 59%, CI (27-93%), p value = 0.027) and the odds of BKS is reduced among students with BMI of 25-29.9 by 45% (odds ratio = 55%, CI (31-95%).Additionally, students with medium or high incomes are more likely to skip breakfast as much as twofold in comparison with students with low income (medium income (odds ratio = 1.85,CI (1.08-3.17),p-value = 0.024), high income (odds ratio = 1.98,CI (1.12-3.51),p-value = 0.019).Lastly, student who are not smoking are 1.6-fold more likely to skip breakfast in comparison with students smoking cigarette.
The data in Table 3 show the relationship between BKS, sociodemographic information and academic performance.The statistical analysis showed that there is a significant relationship between academic performance and income (P = 0.000) and residency (P = 0.000).The data analysis showed that other sociodemographic parameters have no impact on academic performance and BKS.Therefore, it can be understood from Tables 2 and 3 that BKS is related to income, residency and then affects academic performance of the undergraduate students.
Table 4 indicates relationship between breakfast consumption and using Chi-square test.According to the test there is no statistically significant relationship between skipping breakfast and BMI status (Chi-square = 9.11, p-value = 0.69).There is a statistically significant relationship between skipping breakfast and student's income level (p-value = 0.000).BKS among students with BMI of 18-24.9 is reduced by 41% (odds ratio = 59%, CI (27-93%), p value = 0.027) and the odds of BKS is reduced among students with BMI of 25-29.9 by 45% (odds ratio = 55%, CI (31%-95%)We found that there are no relationship between students' skipping breakfast and other factors such as age, gender, BMI, parental education, parental education, study level, study system and material status (Table 5).
Figure 1 shows the reasons for skipping breakfast.The reasons include time constraint (37.2%), lack of appetite (29.3%), breakfast is not ready (16.1%), not hungry (8.3%) and afraid to be overweight (6.1%)Most of the male and female participants indicated that time constraints are the main reason for skipping breakfasts.The statistical data analysis showed that the main reasons provided by students with medium income are either time constraints or lack of appetite.

Discussion
This study is among the early research studies investigating the impact of emergency period on BKS comparing to pre-emergency time.Pandemics like Covid-19 and its confinements and movement limitation can unfavorably affect eating behavior and lifestyle the community [5], particularly university students [6].Regular breakfast is one of the most important factors to improve body wellbeing against several metabolic disorders then improving immune system and reduce risks of the pandemics [13].
The outcome of these study pointed out that the skipping of breakfast is prevalent.It is also obvious that income, BMI and residency have impact on the pattern of the skipping.A very few study have been conducted on this issue.Similar results were seen in earlier study when Japanese female students studied.The BKS were increased during the Covid-19 pandemic [27].On the other hand, another Swedish study discovered that slight increased (0.2%) breakfast consumption was noticed among Swedish students [11].The logistic regression analysis showed that the BKS is prevalent among normal and higher BMI students.This could verify the previous results stating connecting BKS with increasing weight [14].
Income also seems to be affecting BKS; higher income indicates higher BKS.This might due to the eating behavior where students are more comfortable eating snacks with counterparts students than with family.These results are similar to the previous study which found that students from higher family income skip breakfast [3].They have attributed to the tendency of buying more ready-to-eat snacks particularly unhealthy snacks than breakfast due to time constraint as confirmed in Table 6.Similar to that students staying in accommodations skip more breakfast due to time constraint than students living with their families.This was also confirmed by previous Malaysian study [9].The academic performance seems to be affected by BKS in relation to residency and income.In the results of this it was found that students who regularly skip breakfast can feel tired and less focused.This is particularly obvious in low income and students live on accommodation.This is especially seen in the case of Covid-19.This can be attributed to the fact that some of the classes were online and required more attention.When the students cannot pay enough attention they get lower marks.Another factor can be taking unhealthy snacks during Covid-19 as seen in the results that 51% of the students had unhealthy snacks and as it was reported previously that unhealthy snacks were more available during the pandemic [5,15].Previous study also stated that unhealthy snack intake negatively affects students' academic performance [4].
The data have also showed that BKS causes negative health consequences in a short term at the top of them was feeling hungry throughout the day, followed by feeling tired and lack of attention in the class.It has been studied that missing meals or fasting can cause hypoglycemia and trigger headache [26].An earlier study found that BKS is associated with tiredness and poor attention in the class and lower academic performance [1].It is generally accepted that BKS impairs cognitive function and consequently academic performance [8].On the other hand, it was stated that consuming breakfast is associated with a better health [12].
The data analysis indicated that the time constraint is the most common reasons for skipping breakfast along with other reasons including lack of appetite and breakfast unviability.These results are in congruence with those by [2,3,17].These reasons might be due to the fact the many students stay and eat late night [16].Consequently, they do not awake early and prepare breakfast as well as not have appetite to eat.
It is worth mentioning that the main limitation of the study is conducting it online due to the movement restriction and being able to interview students face to face.There was also another factor including psychological parameters that could be studied and might interfere with other parameters.

Conclusion
The aim of present study was to study breakfast skipping frequency, factors associated with, health consequence and undergraduate students academic performance during Covid-19 pandemic as earliest studies focusing on this area.It has been found that factors associated with skipping breakfast are BMI, type of accommodation, and income level.Not having time and not having an appetite were the most common reasons for skipping breakfast.The consequences of skipping breakfast were feeling hungry throughout the day, feeling tired, and not paying attention in class and low academic performance.We also found that having unhealthy snack to compensate skipped breakfast is common.It is important that students follow a healthy diet and

Fig. 1
Fig. 1 Frequency of reason for skipping breakfast

Table 1
Sociodemographic information of the participants

Table 2
Logistic regression analysis of breakfast consumption among university students

Table 5
Relationship between sociodemographic information among student and reasons for skipping breakfast

Table 6
Student's frequency distribution in relation to BKS and health consequence and types of snacks